Icd 10 coding and documentation for subdural hematoma

Subdural hematoma is a type of internal bleeding in the skull.Neurosurgeons or neurology specialists providing treatment for this should ensure that claims are submitted with the correct medical codes. Professional medical coding companies can help ensure accurate documentation and reimbursement.

1. ICD-10 Coding and
Documentation for Subdural
Hematoma
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Subdural hematoma is a type of internal bleeding in the skull. Also referred
to as subdural hemorrhage, the condition occurs when a vein located below
the skull ruptures and starts to bleed. It can be caused by minor accidents
to the head, major trauma, or the spontaneous bursting of a blood vessel in
the brain (aneurysm). Depending on the type and severity of the injury,
surgery can be recommended for subdural hematoma. The most dangerous
type, acute subdural hematoma is usually caused by a vehicle accident or a
blow to the head. Chronic subdural hematoma is caused by mild or
repeated head injuries.
Neurosurgeons or neurology specialists providing treatment for this type of
injuries should ensure that claims are submitted with the correct medical
codes. Professional medical coding companies can help ensure accurate
documentation and reimbursement.

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Symptoms of this condition depend on the type of injury and can vary from
one person to another. Common symptoms include
Severe headache
Vision problems
Slurred speech
Seizures
Mood swings
Loss of consciousness or
passing out
Dizziness and vomiting
Confusion
Apathy and weakness

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Timely treatment helps to minimize the risk of severe
complications and even death. After the initial
testing, diagnostic tests like computed tomography
(CT) or magnetic resonance imaging (MRI) scans
will be conducted to get a clear picture of the
different parts of the brain and to check for any
specific signs of blood clotting.

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Neurosurgery medical coding involves using the specific ICD-10 diagnosis codes
for reporting on the medical claims they submit to health insurers for
reimbursement. The ICD-10 codes for “Subdural Hemorrhage” include
S06.5 –Traumatic subdural hemorrhage
S06.5X –Traumatic subdural hemorrhage
S06.5X0 –Traumatic subdural hemorrhage without loss of consciousness

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S06.5X1 –Traumatic subdural hemorrhage with loss of consciousness of 30
minutes or less
S06.5X2 –Traumatic subdural hemorrhage with loss of consciousness of 31
minutes to 59 minutes
S06.5X3 –Traumatic subdural hemorrhage with loss of consciousness of 1
hour to 5 hours 59 minutes
S06.5X4 –Traumatic subdural hemorrhage with loss of consciousness of 6
hours to 24 hours
S06.5X5 –Traumatic subdural hemorrhage with loss of consciousness
greater than 24 hours with return to pre-existing conscious level

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Even after treatment, many patients may be left with some long-lasting problems
such as mood swings, memory/concentration problems, seizures, speech
problems and weakness in limbs. There are even chances that the symptoms may
come back and surgery may need to be repeated.
Physicians treating such complex conditions
can consider outsourcing medical coding
to a reliable medical billing and coding
outsourcing company, to ensure correct and
timely medical billing and claims
submission.

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